What information about the drug should you determine prior to administration?

Medication administration is a process that carries great responsibility in requiring that you know which medication is supposed to be given, as well as to whom, and when.  Remembering the various information that you need to keep track of can be overwhelming, but it is vital that you are aware of them.  We highly recommend familiarizing yourself with the seven rights of medication administration in order to protect both your patients and yourself.

Right Individual

Making sure that you have the right individual is obviously a very important step in medication administration.  The standard is to check with at least two other sources that you have the correct person before administering medication.  The most experienced of nurses can make a  mistake if tired, overworked, or managing several patients at once.  Despite your level of experience, you should always verify that you are giving the right person the right medication.

Right Medication

It goes without saying that ensuring that you have the right medication is paramount for a variety of reasons. Different patients can have different medical allergies, adverse reactions, and unexpected symptoms that could lead to catastrophic results.  Read the label of the medication, triple-check the patient’s charts, and make sure you are administering the correct medication for that patient.

Right Dose

The right dose is incredibly important as well, as the wrong dose could lead to overdosing a patient and possibly harming them.  The patient’s correct dose should be noted in their chart, and you should also know the form in which they should be receiving medication.  Are they taking pills, receiving medications through IV, or swallowing liquids?  These methods all require various doses. 

Right Time

Many medications have a specific time that they need to be administered, either due to the patient’s other medications or around their meals.  Not all medications require a specific time, but it is your responsibility to know which ones do and don’t.  Every time that medication is given to a patient, it should be recorded so that anyone treating them is aware of when medication was last administered. 

Right Route

“Route” in this case refers to where and how the medication is given to a patient.  While most medications are taken orally, this is not always the case.  The notes surrounding the way that medications should be administered are important to keep communication clear as nurse shifts change or others administer medication.  Medication can be given in several ways including rectally, vaginally, through the skin, in the eyes, in the ears, into the lungs, etc.  This leaves a lot of room for error if not correctly communicated. 

Right Documentation

It is the sole responsibility of the person administering the medication to properly document that administration.  Without proper documentation, communication can get lost between medical professionals.  Always double-check your documentation and make sure that all details are present and correct.

Right Response

Last, but certainly not least, is the response that the patient has to the medication administered.  Anytime that a patient is given medication, their response should be recorded to make sure that it is known to all treating the patient.  Additionally, the level to which the medication helps the patient should be recorded to keep track of what medication is working and what isn’t.  

The research review targeted studies involving medication administration by nurses. This excluded several studies that assessed medication administration errors without differentiating whether the errors were associated with physicians, assistants, or nurses. None of these studies included interventions.

Rates and Types of Medication Administration Errors

Thirteen studies explicitly reported types of MAEs associated with nurses. The incidence of MAEs was detected either formally through incident reports, chart reviews, or direct observation, or informally through anonymous surveys. Two studies conducted retrospective assessments, one using medical records43 and the other malpractice claims.80 Seven studies assessed self-reported MAEs from a nationally representative database44, 81–83 or self-reported errors using a nationally representative sample.84–86 None of these self-reported MAEs were verified. Eight studies assessed MAEs using direct observation of the medication administration process.24, 37, 78, 87–91

The incidence of MAEs varied widely with the different research designs and samples. Using chart reviews, Grasso and colleagues43 found that 4.7 percent of doses were administered incorrectly. Direct observation studies placed the estimate of total incorrect doses between 19 percent and 27 percent,87 and when an extra review was done to separate the errors into stages of the medication process, between 6 percent and 8 percent of doses were in error because of administration. The majority of types of MAEs reported were wrong dose, wrong rate, wrong time, and omission. All of the studies reviewed here reported wrong drug and dose, but varied across the other types of MAE categories (see ); this was dependent upon the study methodology.

Evidence Table 1

Types of Reported and Observed Medication Administration Errors (MAEs)

Five studies evaluated self-reported MAEs, involving incident reports and informal reports.38, 44, 81, 82 The most common types of reported errors were wrong dose, omission, and wrong time. Four of these studies38, 81–83 assessed a large secondary, nationally representative database containing MAEs reported to the MEDMARX database over five years.38, 81, 82, 44 found in the error reports submitted by nursing students that the majority of MAEs were associated with omission, wrong dose, wrong time, and extra dose. Of the reported contributing factors, 78 percent were due to the inexperience of the nurse. The Beyea and Hicks81, 82 studies looked at errors associated with the operating room, same-day surgery, and postanesthesia; they found the majority of errors attributable to administration but did not classify them by error type. The other study reviewed 88 incident reports from a long-term care facility submitted during a 21-month period. It found that the majority of MAEs were associated with errors involving interpreting or updating the medication administration record, delayed dose, wrong dose, or wrong drug.92 A separate component of this study surveyed administrative and clinical nurses and found that they believed the majority of medication errors occurred at either the administration or dispensing stage.

Two other studies assessed the type of MAEs reported by nurses in nationwide surveys.84, 85 While the majority (57 percent) of errors reported by critical care nurses involved MAEs, an additional 28 percent of reported errors involved near misses. Medication administration errors involving wrong time, omission, and wrong dose accounted for 77.3 percent of errors, while wrong drug and wrong patient accounted for 77.8 percent of near misses. The most frequent types of medication errors were wrong time (33.6 percent), wrong dose (24.1 percent), and wrong drug (17.2 percent), and the three most frequent types of near misses were wrong drug (29.3 percent), wrong dose (21.6 percent), and wrong patient (19.0 percent).85 Many of the reported MAEs in ICUs involved intravenous medications and fluids.84 In these surveys, the nurses who reported making errors described between two and five errors during a 14-day period.

At the more advanced stage of incident reports, one study reviewed 68 malpractice cases involving MAEs in Sweden.80 Among the cases reviewed, the majority of MAEs made by nurses involved wrong dose. When the nurses delegated the drug administration to subordinate staff, the majority of MAEs involved wrong drug or wrong concentration of a drug. Errors, which were reported to the immediate supervisor, were also reported to the physician in 65 percent of cases. The reported causes of MAEs were lack of administration protocols, failure to check orders, ineffective nurse supervision when delegating administration, and inadequate documentation.

One study assessed medication errors using 31 medical records of patients discharged from a psychiatric hospital and found a total of 2,194 errors.43 Of these, 997 were classified as MAEs (4.7 percent of all doses, and 66 percent of all errors). Of these, 61.9 percent were due to scheduled doses not documented as administered, 29.1 percent as drugs administered without an order, 8 percent as missed doses because of late transcription, and 3 percent resulting from orders not being correctly entered in the pharmacy computer.

Table 1

Comparison of the Incidence of Medication Administration Errors by Type Categories

The number of studies using direct observation of medication administration is increasing in response to the concern about the accuracy of other sources of data. Ten studies were found, only three of which were done in the United States. While we attempt to summarize across these studies, it is difficult to determine consistency across studies as each focused on different sets of errors (some only intravenous errors, some included gastrointestinal tube technique) and were conducted in different settings. In many of the non-U.S. studies, nurses dispensed drugs from ward stock and prepared many of the intravenous solutions for administration.

Three observational studies were conducted in pediatric units—one in France,78 one in Switzerland,25 and one in the United States.24 Buckley24 reported 52 of the 263 doses (19 percent) observed to be in error, but only 15 (6 percent) of those were in the administration stage. Those 15 were nearly evenly divided among wrong dose, wrong time, wrong technique, and extra dose categories. Prot78 reported nearly 50 percent more MAEs. Of the 1,719 observed doses, 467 (27 percent) were in error, including wrong time; excluding wrong-time errors, the error rate was 13 percent of doses. The categories with the most MAEs in Prot’s study were wrong time, wrong route (GI tube versus oral), wrong dose, unordered drug, wrong form, and omissions. Schneider and colleagues25 reported an overall 26.9 percent error rate with wrong-time errors, and an 18.2 percent rate excluding wrong-time errors. Common errors in addition to wrong time were wrong dose preparation and wrong administration technique.

The incidence of intravenous drug errors was observed in three studies, one in England,89 one in Germany,90 and one in both countries.37 About 50 percent of the doses were determined to contain at least one error. Compared to other studies, this rate is surprisingly high, and it included preparation technique errors (selection of diluent/solvent) as well as administration errors (rate of bolus injection and infusion rate). Part of the explanation may come from institutional (type of pharmacy support available) and professional training factors. (German nurses are not trained to do intravenous medications.)

Three studies focused on medication administration in ICUs in the United States,45 in France,91 and in the Netherlands.94 Kopp and colleagues45 looked at all medication errors and report that 27 percent of doses were in error; of these 32 percent could be attributed to the administration stage. Within the MAEs, most were omitted medications; the rest were evenly distributed among wrong dose, extra dose, and wrong technique. Few wrong-time errors were noted. Tissot91 and van den Bernt94 examined only administration stage errors and reported very different rates. Tissot reported 6.6 percent of the 2,009 observed doses were in error, most from wrong dose, wrong rate, and wrong preparation technique. Excluding wrong-time errors, van den Bernt reported a 33 percent error rate that included preparation errors with diluent/solvent issues, infusion-rate errors, and chemical incompatibility of intravenous drugs. It is likely that the differences in rates across these studies are due to the range of error types observed in each study as well as the varying responsibilities of nurses in the three countries.

The most extensive observation study, by Barker and colleagues,87 conducted observations of medication administration in 36 randomly selected health care facilities (acute and long-term care) in two States in the United States. Of the 3,216 doses observed, 605 (19 percent) contained at least one error. Nearly half of those errors were wrong-time errors. Other common types of errors included omission, wrong dose, and unauthorized (unordered) drug. In a much smaller study conducted in the Netherlands, Colen, Neef, and Schuring88 found an MAE rate of 27 percent, with most of these wrong-time errors. The rate of MAEs without wrong time was approximately 7 percent, and most of those were omissions.

Information from these research studies forms a consistent picture of the most common types of MAEs. These are wrong time, omissions, and wrong dose (including extra dose). Rates of error derived from direct observation studies ranged narrowly between 20 and 27 percent including wrong-time errors, and between 6 and 18 percent excluding wrong-time errors. The alarming exception to this was the nearly 50 percent error rate in observation of intravenous medication in ICUs in Europe.